DR. TODD JAROTSKI D.M.D., M.SC.

DR. MICHAEL LAM D.M.D., M.SC.

PATIENT INFORMATION:

Patient Name:

Birth date:

Age:

Address:

City/Town:

Postal Code:

Phone: Home:

Cell/other:

How do you wish to be reminded of your appointments (check off all that apply)?

Email (parent/guardian):

Email (patient):

Cell number for text messages:

May we email your receipts and any further appointment information?

Yes No

IF PATIENT IS A MINOR:

Parent/guardian name:

Relationship:

Work Number:

Parent/guardian name:

Relationship:

Work Number:

May we contact you at work?

Yes No

What are the patient's concerns regarding the teeth and jaws?

Whom may we thank for referring you to our office?

MEDICAL HISTORY:

Physician:

Last medical check-up:

Present health status:

Past severe illnesses?

Yes No

Past hospitalization?

Yes No

Past facial trauma?

Yes No

Current medications?

Yes No

Allergies (medications, latex, nickel, etc)?

Yes No

If yes to any of the above, please explain:

DENTAL HISTORY:

Dentist:

Last dental check-up:

How often do you go for dental check-ups?

Have the following ever been present?

Thumb or finger sucking Tooth grinding/clenching Speech problem Other jaw problems

If yes to any of the above, please explain:

FINANCIAL RESPONSIBILITY:

Person financially responsible for the orthodontic treatment of

Name:

Phone:

Address:

Postal Code:

Do you have a dental plan covering orthodontic treatment?

Yes No

Signature of financially responsible party

INSURANCE INFORMATION:

Do you have a dental plan covering orthodontic treatment?

Yes No

If Yes:

Name of Insurance Company/Companies:

Group/ Policy #:

Certificate/ ID #:

Subscriber Name:

(Please ask if you require assistance with your insurance information)

We do not direct bill insurance companies but would like your insurance information on file.

ADDITIONAL COVERAGE:

Do you have supplementary coverage through Family Health Benefits?

Yes No

Health services #

Do you have coverage through First Canadian Health?

Yes No

Client identification #

Do you have a second dental plan covering orthodontic treatment?

Yes No

If Yes:

Name of Insurance Company/Companies:

Group/ Policy #:

Certificate/ ID #:

Subscriber Name:

ACKNOWLEDGEMENT AND CONSENT:

I acknowledge Saskatoon Orthodontics' Privacy Policy and understand my rights of privacy with respect to my personal information. I further consent to the collection, use and disclosure of my personal information for the following services:

To provide me with orthodontic services To maintain communications and provide me with information and follow up respecting my orthodontic care To obtain payment of my account For the uses, purposes and disclosures described in the Privacy Policy

Other:

Restricted Access - My personal information shall not be provided to the following individuals or organizations:

Restricted Information - Personal information disclosed from personal information collected shall not include:

Signature / Signature of parent if a minor